Reference no: EM133281174
Case Scenario
J.M. is a 71-year-old man diagnosed with type 2 diabetes 10 years ago with an average blood sugar of 220 mg/dL. In addition, J.M. was diagnosed with heart failure 15 years after his five vessel coronary artery bypass grafts (CABGs). The cardiac history is a result of the untreated hypertension he suffered from for 12 years before his bypass surgery. Physical assessment data reveal oral temperature 98.4°F, respiratory rate 10 breaths/min, apical pulse 128 beats/min, blood pressure 186/96 mm Hg, and pulse oximetry is 80%, and crackles scattered throughout all lung fields. J.M. complains of shortness of breath (SOB) with activity, denies pain, is able to perform ADLs, states problems with swallowing thin liquids, and requests to be placed in high-Fowler's position. Respiratory pattern is irregular and shallow. J.M. is oriented to person and place, and skin is cool, moist, and pale. Bowel sounds are active in all four quadrants, and the abdomen is semihard and slightly distended. J.M. has (12) pitting edema to the lower extremities.
The following questions will guide your development of a nursing care plan for this case study.
1. List subiective and obiective assessment data.
2. What acid-base imbalance does the nurse suspect?
3. Select three priority nursing diagnoses for J.M.'s acid-base imbalance.
4. Choose the priority nursing diagnosis and develop an appropriate client centered goal.
5. What nursing interventions should the nurse implement to assist J.M.?